Luciano Isolan

Treating Medication-Resistant Panic Disorder: Predictors and Outcome of Cognitive-Behavior Therapy in a Brazilian Public Hospital

Background: In Brazil, treatment of panic disorder is most frequently initiated with pharmacotherapy, but only half of the patients can be expected to be panic free after medication. Studies have suggested that individual or group cognitive-behavior therapy (CBT) is an effective treatment strategy for panic patients who have failed to respond to pharmacotherapy. Methods: Thirty-two patients diagnosed with panic disorder with agoraphobia having residual symptoms despite being on an adequate dose of medication were treated with 12 weeks of group CBT. The outcome was evaluated for panic frequency and severity, generalized anxiety, and global severity. Comorbid conditions, a childhood history of anxiety, and defense mechanism styles were assessed as potential predictors of treatment response. Results: Twenty-nine patients completed the 12-week protocol. Treatment was associated with significant reductions in symptom severity on all outcome measures (p < 0.001). Patients with depression had a poorer outcome of the treatment (p = 0.01) as did patients using more neurotic (p = 0.002) and immature defenses (p = 0.05). Conclusion: Consistent with previous reports, we found that CBT was effective for our sample of treatment-resistant patients. Among these patients, depression as well as neurotic defense style was associated with a poorer outcome. The use of CBT in Brazil for treatment-resistant and other panic patients is encouraged.

Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Brazilian children and adolescents.

The aim of this study was to evaluate the psychometric properties of the Brazilian-Portuguese version of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in a large community sample of Brazilian children and adolescents. A total of 2410 students completed the 41-item Brazilian-Portuguese version of the SCARED. The one-factor and the five-factor structure of the SCARED fit this sample well. However, the five-factor model had a significantly better fit than the one-factor model and an adequate fit for age and gender subgroups. Anxiety symptoms in Brazilian youth were reported at a moderate-high level as compared to other studies. Females were found to score significantly higher on the total score and on all of the subscales as compared to the males. The total score and each of the five factors for both children and adolescents showed good internal consistency, test-retest and construct validity. According to our findings the Brazilian-Portuguese version of the SCARED is a reliable and valid instrument to assess anxiety in Brazilian children and adolescents.

Evaluation of defense mechanisms in adult patients with panic disorder: before and after treatment.

Patients with acute panic disorder (PD) use a more maladaptive pattern of defense mechanisms. This study investigated the use of defense mechanisms by patients with acute symptomatic PD and those in complete remission. Thirty-three patients and 33 controls were evaluated by the Mini International Neuropsychiatric Interview. The defense mechanisms were evaluated by the Defense Style Questionnaire at the beginning of the study and after 16 weeks of sertraline treatment. Panic disordered patients used more neurotic (4.6 vs. 3.6; p = 0.003) and immature (3.6 vs. 3.0; p = 0.024) defenses at baseline. Patients who achieved complete remission (N=25) differed from the control group in the use of neurotic defenses at the baseline (4.4 vs. 3.6; p = 0.033). After treatment, they showed a reduction in the use of neurotic (4.4 vs. 3.7; p=0.014) and immature (3.4 vs. 3.1; p = 0.019) defenses. Defense mechanisms in PD are influenced by the presence of symptoms, severity, and outcome of the disease.

Brazilian patients with panic disorder: the use of defense mechanisms and their association with severity.

This study aims to evaluate the defense mechanisms most frequently used by Brazilian patients with panic disorder when compared with a control group. The study also examines the association between severity of disease and comorbidity and the use of specific defense mechanisms. Sixty panic-disordered patients and 31 controls participated in the study. The Mini International Neuropsychiatric Interview was used to confirm the panic disorder diagnosis and to establish the comorbid diagnosis. The Clinical Global Impression (CGI) was used to assess severity and the Defensive Style Questionnaire (DSQ-40) was used to evaluate the defense mechanisms. Panic patients used more neurotic (mean = 4.9 versus 3.6; p < 0.001) and immature (mean = 3.9 versus 2.8; p < 0.001) defenses as compared with controls. Panic patients with severe disease (n = 37; CGI>4) had more depression comorbidity and used more immature defenses than patients with CGI≤4 (n = 23; mean = 4.2 versus 3.5; p < 0.001). It was concluded that the panic severity and depression comorbidity found in Brazilian panic-disordered patients are associated with the use of maladaptive mechanisms, namely immature defenses.

The multidimensional evaluation and treatment of anxiety in children and adolescents: rationale, design, methods and preliminary findings

OBJECTIVE This study aims to describe the design, methods and sample characteristics of the Multidimensional Evaluation and Treatment of Anxiety in Children and Adolescents - the PROTAIA Project. METHOD Students between 10 and 17 years old from all six schools belonging to the catchment area of the Primary Care Unit of Hospital de Clínicas de Porto Alegre were included in the project. It comprises five phases: (1) a community screening phase; (2) a psychiatric diagnostic phase; (3) a multidimensional assessment phase evaluating environmental, neuropsychological, nutritional, and biological factors; (4) a treatment phase, and (5) a translational phase. RESULTS A total of 2,457 subjects from the community were screened for anxiety disorders. From those who attended the diagnostic interview, we identified 138 individuals with at least one anxiety disorder (apart from specific phobia) and 102 individuals without any anxiety disorder. Among the anxiety cases, generalized anxiety disorder (n = 95; 68.8%), social anxiety disorder (n = 57; 41.3%) and separation anxiety disorder (n = 49; 35.5%) were the most frequent disorders. CONCLUSION The PROTAIA Project is a promising research project that can contribute to the knowledge of the relationship between anxiety disorders and anxiety-related phenotypes with several genetic and environmental risk factors.

Do defense mechanisms vary according to the psychiatric disorder

OBJECTIVE The aim of this study was to evaluate the defense mechanisms used by depressive and anxious patients without comorbidities compared to those used by controls and to determine whether these patterns differ between diagnoses. METHOD The sample was composed of 167 psychiatric patients and 36 controls that were evaluated using the Defense Style Questionnaire 40. All subjects were evaluated through a clinical interview, and each evaluation was confirmed through the application of the Mini International Neuropsychiatric Interview, a structured psychiatric interview. We used ANOVA and discriminant analysis to assess differences between groups. RESULTS Neurotic defense mechanisms discriminated controls from all patients except those with social anxiety. Immature defense mechanisms differentiated controls from all patients, as well as distinguished depressive patients from panic disorder and obsessive disorder patients. The discriminant analysis indicated that depressive patients are characterized by projection, panic disorder patients by sublimation and obsessive-compulsive patients by acting out. CONCLUSIONS Depressive and anxious patients differ from other individuals in their use of defense mechanisms, and each diagnosis has a particular pattern. These findings could lead to the development of specific psychotherapeutic interventions.

An open-label trial of escitalopram in children and adolescents with social anxiety disorder.

Social anxiety disorder (SAD) is a highly prevalent and disabling disorder in children and adolescents. This study was designed to evaluate the efficacy and safety of a highly potent and selective serotonin reuptake inhibitor, escitalopram, in the treatment of SAD in children and adolescents. Twenty outpatients with a primary diagnosis of SAD were treated in a 12-week open trial with escitalopram. The primary outcome variable was the change from baseline to end point in Clinical Global Impression-Improvement scale (CGI-I). Secondary efficacy measures included the CGI-Severity scale (CGI-S), the Social Phobia and Anxiety Inventory for Children (SPAI-C), the Screen for Child and Anxiety Related Emotional Disorders (SCARED)-Child and Parent version, and The Youth Quality of Life Instrument-Research Version (Y-QOL-R). On the CGI-I scale, 13 of 20 patients (65%) had a score < or =2, meaning response to treatment. All symptomatic and quality of life measures showed improvements from baseline to week 12, with large effect sizes ranging from 0.9 to 1.9 (all p < 0.001). Escitalopram was generally well-tolerated. These results suggest that escitalopram may be an effective and safe treatment for pediatric SAD. Future double-blind, placebo-controlled, randomized clinical trials are warranted.

Quality of Life and Treatment Outcome in Panic Disorder: Cognitive Behavior Group Therapy Effects in Patients Refractory to Medication Treatment

Background: Improvements in quality of life (QoL) as well as symptomatic relief are important outcomes for the treatment of panic disorder (PD). The aim of this study is to assess the impact of brief cognitive behavior group therapy (CBGT) for panic disorder on QoL and to identify the clinical features associated with these changes. Methods: Thirty-six patients with PD refractory to pharmacological treatment took part in a treatment protocol consisting of 12 sessions of CBGT. To evaluate the changes in QoL, the WHOQOL-bref was administered before and after treatment. Results: Thirty-two patients completed the treatment. Significant improvement in all domains of QoL was observed (p< 0.001), which was associated with reductions in general and anticipatory anxiety (p = 0.018) and agoraphobic avoidance (p = 0.046). Consistent with previous findings, associations between QoL and panic-free status did not reach significance in this small study (p = 0.094). Conclusions: CBGT was efficacious in the treatment of PD; the symptoms of anticipatory anxiety and avoidance appear to be more important than episodic panic episodes in affecting QoL.

Brazilian–Portuguese version of defensive style questionnaire-40 for the assessment of defense mechanisms: construct validity study

Abstract The aim of this study is to analyze the reliability and validity of the Brazilian–Portuguese version of the Defensive Style Questionnaire (DSQ). Participants were evaluated by clinical interview and the Mini-International Neuropsychiatric Interview. Reliability was assessed by factor analysis and Cronbachs alpha. The 3-factor models replication was tested using confirmatory factor analysis (CFA). Controls were reevaluated after 4 months to assess test–retest reliability. Subsamples were also evaluated using the Minnesota Multiphasic Personality Inventory and Defensive Functioning Scale (DFS). Factor analysis of the various defense mechanisms produced a distribution of mechanisms among the factors that was largely similar to previous analyses based on the original instrument. The 3-factor model was supported by CFA. The test–retest evaluation showed sufficient intraclass correlation for all factors. Patients used more immature and neurotic defenses than controls. There was a correlation between DFS and immature defenses. Individuals with pathological personality traits scored higher on the immature and neurotic factors than those without. The Brazilian–Portuguese version of the DSQ-40 has psychometric features that allow the use of this instrument in our culture.

Estudo retrospectivo da associação entre transtorno de pânico em adultos e transtorno de ansiedade na infância

OBJETIVO: A etiologia do transtorno do pânico (TP) e provavelmente multifatorial, incluindo fatores geneticos, biologicos, cognitivo-comportamentais e psicossociais que contribuem para o aparecimento de sintomas de ansiedade, muitas vezes durante a infância. O objetivo deste estudo foi avaliar a relacao entre historia de transtornos de ansiedade na infância e transtorno do pânico na vida adulta. METODOS: Foram avaliados retrospectivamente 84 pacientes adultos com transtorno do pânico quanto a presenca de historia de transtornos de ansiedade na infância, por meio de uma entrevista estruturada (K-SADS-E e DICA-P). A presenca de comorbidades com outros transtornos de ansiedade e de humor foi avaliada por uma revisao de registros medicos. RESULTADOS: Observou-se que 59,5% dos pacientes adultos com TP apresentavam historia de ansiedade na infância. Encontrou-se uma associacao significativa entre a presenca de historia de transtorno de ansiedade generalizada na infância e a presenca de comorbidades com o TP na vida adulta, como agorafobia (p=0,05) e depressao (p=0,03). CONCLUSOES: Este estudo sugere que a historia de transtorno de ansiedade na infância pode ser considerada um preditor de maior gravidade para o transtorno do pânico na vida adulta.